This proposed intervention study addresses the Program Announcement, Long-Term Care Quality of Life and Quality of Care. In this study, we seek to improve the outcomes of residents by transforming poorly performing nursing home staffs into good ones - a task of pressing national importance. We propose to accomplish this by bundling the best clinical and management approaches gleaned from our preliminary work and from a formerly fragmented set of studies by others, including organizations as complex adaptive systems. Our intervention will be comprehensive, and it will be the first to work at multiple levels: We will work side-by-side with the firmly guide direct-care direct care staff at poorly performing nursing homes to facilitate their adoption of excellent care systems and practices. We will also foster a professional and inclusive nursing management style and an organizational culture that embraces on-going improvement and systematically carries quality-improvement practices forward. Based on our recently completed NINR-funded study, "Nursing Care Processes, Outcomes and Cost in Nursing Homes" (1998-2003, Rantz, PI), we have designed a randomized, two-group, repeated-measures design to test a two-year experimental intervention for improving quality of care and subsequently improving resident outcomes in nursing homes. Facilities with resident outcomes in need of improvement will receive an experimental multilevel intervention that helps staff (1) use quality-improvement methods, (2) use team and group process for direct-care decision-making, (3) focus on accomplishing the basics of care and (4) maintain more consistent nursing and administrative leadership committed to communication and active participation of staff in decision-making. The multilevel intervention will involve all levels of nursing home staff; that is, owners, administrators and direct-care staff at 64 facilities in three states. We will use both qualitative and quantitative methods to measure the effectiveness of the intervention. An attention control group will receive information about aging and physical assessment of elders. We will measure resident outcomes with selected quality indicators from nursing home Minimum Data Set: bladder and bowel incontinence, weight loss, pressure ulcers and decline in activities of daily living (ADL). We will measure staff retention; direct-care costs, total costs, and detailed costs; staffing and staff mix, and employees' views of selected organizational attributes before, during and after the intervention. Similarly, we will observe processes of care delivery before, during and after the multilevel intervention to describe the adoption of the care delivery strategies recommended in the intervention.